Dermatology Case Study 10

INITIAL OFFICE EVALUATION

This patient developed a persistent lesion on the inner aspect of the left upper lip.  This lesion was at the junction of the vermilion and mucous membrane.  A punch biopsy was obtained of this 1-cm lesion and was read as a probable verrucous squamous cell carcinoma of the lower lip.  One month later a wedge excision revealed no residual carcinoma, but there was adjacent actinic cheilitis.

She did well until June when some early irregularity of the area was noted.  A biopsy showed recurrent, superficially invasive squamous cell carcinoma which was totally removed by the punch biopsy, with an intraepithelial squamous cell extending to the punch biopsy margin.  Because of the recurrence and because the patient is fearful of additional surgery, she is seeking a second opinion.

She smokes 1 to 1-1/2 packs of cigarettes per day and has done so for the past 50 years.  She is not a gum chewer and does not have any habit of chewing any other substance in her mouth.

On examination today, there is a well-healed 1.25-cm surgical scar on the left lower lip which extends over the vermilion onto the mucous membrane.  At the present time there is no nodule, irregularity, or active lesion, and the recent biopsy site is well healed.  There is, however, thickening and fibrosis of the incision line.  Examination of the submental, anterior, and posterior cervical lymph nodes was negative.

I have explained at length the nature of the recent pathological findings and have drawn them out for her on paper.  I have advised her that there is residual irregular tissue which does not at the present time show invasion but must be excised or she may continue to get recurrent invasive areas which could eventually metastasize.  I strongly advised her to quit smoking due to the dyskeratotic change of her oral mucosa.  The lip lesion is occurring at the point where maximum heat and tar deposition would occur from cigarettes.  Although one cannot absolutely prove that this is a major factor, I feel that smoking should be discontinued in any patient who shows this type of change in the oral mucosa.  She asked about the possibility of agents to help her quit smoking.  I feel that agents such as Nicorette are contraindicated because their nicotine content will exacerbate her Buerger disease.  There have been some recent reports of oral clonidine being helpful in patients attempting to withdraw from nicotine.  It would be worthwhile to give it a trial since she is sorely addicted to nicotine, as are most patients with Buerger disease.

She asked me whether or not radiation therapy was appropriate.  I advised her that these tumors are not particularly responsive to radiation therapy and, in fact, in the long run, this modality might tend to spread or accelerate the problem.  The treatment preferred is surgical.

FOOTNOTE

Lines 9, 12, 29 (Page 1).  The physician says upper lip and then lower lip.  The transcriptionist on the job would ask the physician for clarification or check the patient’s health record.

Line 4 (Page 2).  Buerger disease (a vascular disorder), not Berger disease (a kidney ailment).